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k <br />• WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT 1 -;ALL (ZUV) V0J-/by/ FOR INSPECTIONS <br />tANIKtb l TEAR FROM DATE ISSUED <br />JOB ADDRESS 2777 E Nile Avenue <br />CITY/ZIP <br />Manteca, CA 95337 <br />cm <br />•■■■■■■■■■■■■■■■■■■■■■1111■■■■■■■■■!I■ll■■■■1:.1 <br />CROSS STREET APN 241-230-040 <br />PARCEL SIA4-5 <br />LAND USE APPLICATION # <br />OWNER NAME John and Michell Machado <br />PHONE 209.985.5816 <br />OWNER ADDRESS 6909 Devision avenue <br />CITYISTATEIZIP <br />Monteca, Ca 95337 <br />CONTRACTOR One Source Drilling & Pumos <br />■■■■■■■■■■■■■■■■■■■■■1111■■■■■■■■■■►:�1■■■■■■■■■ <br />PHONE (A?S) 7AR-9015 <br />CONTRACTOR ADDRESS 3494 Camino Tassajara # 227 <br />CITY/STATE/ZIP <br />Danville, Ca 94506 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other <br />NUMBER 1002672 <br />EXPIRATION DATE 04/2017 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE Domestic/Private Xlrrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name ContaCt Name or one NUMber <br />TYPE OF WORK X New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) x of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />#of* 1 1 <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 400 it Excavation 24 in diameter Open Bottom X Gravel Pack/Gravel Size 3/8 in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter 16 in Thickness/Gauge/ASTM Sched 0.250 X Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 it Neat Cement (94 /b bag/5-f0 gal water) Sand Cement I • _sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall Other Retardant / Accelerator (name) 10.3 sk sand slurry <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width it Length it Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set it Standing Water Level it <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE FALIFORNIA CONTRACT RS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAW <br />MINIMUM 24 HOU <br />AD FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Anna Nahlik ITLEowner DATE 07/08/9015 <br />y <br />DEPARTMENT USE ONLY <br />Application Accepted By CC Date 4 Area Employee ID# 46 4� `f <br />r <br />Grout Inspection Byeo!" G C10D Date 717 -1 l� Pet Per 1") 11' SPECIAL Well Permit <br />Pump Inspection By Date cammty} WAIVER Received <br />Soil Boring InspectioBy Dale Constructed Well Depth ft <br />COMMENTS FinG1uP )Y1 SP ' J r► ,oP JZ;fer, r D 1/ak <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />cm <br />•■■■■■■■■■■■■■■■■■■■■■1111■■■■■■■■■!I■ll■■■■1:.1 <br />' ■■■■■■■■■■■■■■■■■■■■■1111■■■■■■■■■!tl`il■■■■YY■ir <br />■il■ <br />'■■■■■■■■■■■■■■■■■■■■■1111■■■■■■■■■11L!11■■■■■■■■■ <br />"'■■■■■■■■■■■■■■■■■■■■■1111■■■■■■■■■!!`ll■■■■■■■11111 <br />I ' <br />■■■■■■■■■■■■■■■■■■■■■1111■■■■■■■■■■►:�1■■■■■■■■■ <br />■■■■■■■■■■■■■■i■i■iii►ii�i�:iiiiiiiiiill■■■■■■■■■ <br />DEPARTMENT USE ONLY <br />Application Accepted By CC Date 4 Area Employee ID# 46 4� `f <br />r <br />Grout Inspection Byeo!" G C10D Date 717 -1 l� Pet Per 1") 11' SPECIAL Well Permit <br />Pump Inspection By Date cammty} WAIVER Received <br />Soil Boring InspectioBy Dale Constructed Well Depth ft <br />COMMENTS FinG1uP )Y1 SP ' J r► ,oP JZ;fer, r D 1/ak <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />